30. Before we decide if we should conduct a detailed investigation of a complaint, we look at whether there are signs the organisation has got something wrong. We do this by comparing what should have happened with what did happen. We have done this and have not seen any indications that something has gone wrong. We have explained why below.
Refused a face-to-face appointment
31. Mrs P complains the Centre refused her request for a face-to-face appointment in mid2022
32. The GMC’s Good Medical Practice says medical professionals must:
• adequately assess the patient’s conditions, taking account of their history (including the symptoms and psychological, spiritual, social, and cultural factors), their views and values; where necessary, examine the patient • promptly provide or arrange suitable advice, investigations, or treatment where necessary • refer a patient to another practitioner when this serves the patient’s needs.
33. We can see from the records available that following the OGD and CT contrast enema, Mrs P had a telephone consultation with the Centre in mid-May 2022. The GP noted she likely had haemorrhoids although they could not be sure, due to the telephone consultation. The GP prescribed a new haemorrhoid treatment and advised Mrs P to book a face-to-face appointment if the matter was not resolved after two weeks. We have seen no indication Mrs P did this.
34. From this consultation to September 2022, Mrs P had several further telephone consultations with the Centre. During these appointments, the Centre provided advice and prescribed different treatments for her symptoms.
35. We can also see she had a face-to-face consultation in July 2022 but note the record of this consultation indicates her haemorrhoids symptoms had improved at this point. There is no record of her raising concerns regarding her haemorrhoids or requesting the GP examine her during this appointment.
36. We have been unable to see any indication the Centre refused a request to provide Mrs P with a face-to-face consultation.
37. As part of our investigation of Mrs P’s complaint, we asked our adviser to review her medical records. We did this to see if there was any indication the Centre had not acted in line with relevant guidance or standards.
38. Our adviser explained that haemorrhoids are a very common condition. They referred to the NHS’s website page regarding piles (haemorrhoids), which gives people information and advice about the condition. The website says a GP may prescribe stronger medicines for piles or constipation. It says a GP may also check their symptoms are not being caused by something else.
39. We can see the GPs prescribed different haemorrhoid and constipation medication when Mrs P’s symptoms failed to resolve. The Centre also considered other causes for her symptoms, which had been found during the investigations by Trust B.
40. We acknowledge Mrs P has experienced pain and stress due to her haemorrhoids. We also acknowledge she considers the Centre should have done more to limit the pain she felt.
41. We have seen no indication the Centre failed to act in line with the GMC Good Medical Practice when it completed the consultations with Mrs P between May 2022 and September 2022. We can see it provided her with advice and prescribed different treatments for her to try and resolve the matter. Furthermore, we have seen no indication the Centre refused to provide Mrs P with a face-to-face consultation.
42. As we have seen no indication something has gone wrong here, we have decided to not to consider this element of Mrs P’s complaint further. We hope our explanation has provided Mrs P with some reassurance about the care she received.
Haemorrhoids identified but not noted
43. Mrs P says the nurse from Trust B who prepared her for the CT contrast enema in early 2022 identified she had haemorrhoids. Mrs P complains the nurse did not inform the consultants or the colorectal team of this.
44. Within its response, Trust B explained that Mrs P was referred to it on a two week wait referral. It further explained this pathway is set up to rapidly diagnose cancers. Trust B noted that as part of Mrs P’s assessment, a comprehensive history was taken and documented. It stated it noted she was anaemic and so was offered an OGD and a colonoscopy. Furthermore, it stated Mrs P declined the colonoscopy and so went on to have the OGD and a CT contrast enema.
45. We note that although we have requested them, we have not received any documents regarding the CT contrast enema from Trust B. After making a further request for this information on 12 November 2025, Trust B informed us the procedure was performed at a private hospital. The private hospital has said it cannot find records for Mrs P.
46. With the above being said, we asked our specialist adviser to review the documents we do have and to provide clinical advice. We did this to establish what should have occurred following the nurse identifying Mrs P had haemorrhoids. The lack of records has however limited what we can say here.
47. Our specialist adviser confirmed that Mrs P’s GP referred her on the two-week suspected cancer pathway. They noted there is no mention of haemorrhoids on the referral form. They stated the colorectal team were investigating for any signs of colorectal cancer due to Mrs P having anaemia and changes in bowel habit.
48. Our specialist adviser noted Trust B’s pre-assessment document does not include information regarding a clinical examination. They stated this may indicate it was a telephone assessment. Furthermore, they noted there is also no mention of haemorrhoids on this document.
49. So far, we are satisfied that Trust B was not aware Mrs P had, or may have, haemorrhoids.
50. Our specialist adviser explained that to prepare a patient for a CT contrast enema, a tube such as a catheter tube is inserted into the patient’s rectum. They said this is done so air can be pumped into the bowel to inflate it to provide a fuller view of it on the scan. They stated that haemorrhoids would not be visible on a CT colonography, but they may have been visible while the tube was inserted.
51. There is no documentation available to confirm what type of tube was inserted, or who inserted it into Mrs P’s rectum. There is also no documentation to say whether or not haemorrhoids had been seen while the tube was inserted, and if they were, the degree or location of these. This is where the lack of records has impacted our consideration of Mrs P’s complaint.
52. The GMC’s Good Medical Practice says doctors must promptly provide or arrange suitable advice, investigations or treatment where necessary. They must also refer a patient to another practitioner when this serves the patient’s needs.
53. The specialist adviser has explained that in the event of haemorrhoids being identified that do not meet the criteria for referral, an organisation would not be expected to make any referrals or complete any further investigations. They said in this scenario, patient advice should be given regarding treatment and management of haemorrhoids and the patient be discharged to their GP for ongoing management.
54. The NICE guidance sets out when clinicians should refer patients for non-urgent assessment and management. This includes when:
• fourth degree haemorrhoids or third degree haemorrhoids which are too large for non-operative measures (haemorrhoidectomy may be needed) • combined internal and external haemorrhoids with severe symptoms (surgery may be required) • thrombosed haemorrhoids when bleedings is problematic, or there is chronic irritation or leakage.
55. The NICE guidance set out above gives the scenarios when clinicians should refer a patient. This includes if a person has large third degree or fourth degree haemorrhoids, or where the person has combined internal and external haemorrhoids with severe symptoms. A third degree haemorrhoid is a much larger haemorrhoid which protrudes outside the anal canal and only goes back inside when manually pushed back. A fourth degree haemorrhoid is where it hangs outside of the anus, and cannot be manually pushed back inside.
56. We have considered whether at the time of the CT contrast enema procedure in early 2022, it is possible to say whether Mrs P’s haemorrhoids would have likely met the criteria set out in paragraph 54.
57. We can see in mid-October Mrs P’s GP identified she had a large external haemorrhoid. But we can also see the private consultant Mrs P saw in December 2022 documented she had second degree internal haemorrhoids and an anal polyp (with no external haemorrhoid noted).
58. There is differing information available about what stage Mrs P’s haemorrhoids were at different times after the procedure. Given in December 2022, the haemorrhoid was noted to be second degree, it is possible that earlier in the year it was still either first or second degree. If this was the case, a referral was not required in line with the NICE guidance.
59. We know from what our adviser has said that an internal haemorrhoid would not be visible on the CT colonography. We therefore think even if Trust B had noted Mrs P had an external haemorrhoid at the time of the procedure, it could not have determined these met the second criteria set out in paragraph 54. It would not have been able to tell whether she had combined internal and external haemorrhoids.
60. The NICE guidance also says a referral should be made if there are thrombosed haemorrhoids when bleedings is problematic, or there is chronic irritation or leakage then a referral is required.
61. We can see from Mrs P’s medical records that she informed a GP in mid July 2022 that there was no longer any blood present when wiping. We note there is no further mention of Mrs P experiencing bleeding in the three GP consultations held between August and October 2022. We therefore do not think Mrs P had met the criteria set out in the paragraph above.
62. With the above in mind, we consider the evidence available indicates that at the time of the CT contrast enema scan, it is likely Mrs P’s haemorrhoids did not meet the criteria for onward referral.
63. We recognise not having the documentation following the CT contrast enema scan has left some uncertainty here. On the balance of probabilities, we consider it is likely Trust B appears to have acted in line with the NICE guidance and the GMC’s Good Medical Practice when it discharged Mrs P back to her GP without making any onward referrals.
64. We acknowledge how much pain Mrs P’s haemorrhoids caused her over a prolonged period, and we understand how distressing this was for her. Because we have seen no indication something has gone wrong, we have decided not to consider this element of Mrs P’s complaint further.
65. We would like to thank Mrs P for providing us with the opportunity to review her concerns regarding the Centre and Trust B.